Medical Dilemmas Transplant Procurement - Essay Example

Introduction I have been involved in the healthcare profession as a Haemodialysis nurse for twenty years. In my practice, I have witnessed the agonynot only of the patients, but of their families as well looking forward for a renal transplantation. This became more pronounced as I became in charge of the haemodialysis unit. In 2005, I had been trained in Transplant co-ordination and Transplant procurement management. I realize that it is a challenging role to be in such a position firstly because human organ transplantation has become a controversial issue due to the unbalanced ratio of patients in need and organ donors and secondly, the policies that govern organ transplantation have caused a lot of conflicts. Since then my duties included, among many others, locating potential cadaveric donors and assisting in organ donation by conferring, counselling and supporting the donor’s family. Policies that govern organ donation have been conflicting. Originally, organ donation was purely altruistic, and procedures were done from one close kin to another. However, the rapid increases in organ demand due to prevalent diseases that necessitate it, have pointed to other alternatives such as cadaveric organ donations. In Cyprus, the Cyprus National Transplant Procurement Policy (CNTPP) was created by the Ministry of Health as a law proposal to the council of ministers. The proposal was finally legalized by the parliament as an act and was given the name “Act for Abstraction and Transplantation of Biological Human Substances of 1987” (Cyprus, 1987), which is summarised in appendix “A”. It was created to control live and cadaveric organ donation and transplantation. This study therefore, will highlight some insights into this issue which has remained very controversial and which has posed major medical dilemmas. In the process, the influence that policy has on practice as well as the influence that practice has on policy will be discussed. Finally, some issues that will affect the future will be raised.   Impact of Policy on Practice Colebatch sees policy as a cloak that makes organized activity stable and predictable. Policy has two dimensions: vertical and horizontal. The vertical dimension sees policy as a rule taking on a “top-down” perspective. This dimension is concerned with the transmission of the policy downwards from authorized decision-makers to subordinate officials expected to implement the policy. On the other hand, the horizontal dimension of policy sees policy as shared among policy participants from and across various organizations. In terms of impact, the vertical dimension of policy affects how practitioners interpret and implement the policy handed down to them from the top. The horizontal dimension of policy sees it in practice amongst policy participants and can affect how policy may be altered to benefit more people. Policies on organ transplant procurement have indeed affected medical practice. Doubtless, there is an organ shortage, as the waiting lists of prospective organ recipients lengthen year after year. Kaserman & Barnett (2002), claim that this is not due to an inadequate supply of potential organ donors but due to the restrictive policies of organ procurement. CNTPP has impacted my practice, mainly in two ways, the cadaveric donation and donation from living humans. Although CNTPP from its formation was considered an altruistic policy it eventually developed to provide insufficient incentives for cadaveric donation. Some of the major insufficiencies include but are not limited to the following: The general lack of effective information dissemination about the policy on cadaveric donation causes suspiciousness in the families of the deceased potential organ donor. They may distrust hospital personnel who approach them regarding matters of organ donation and become wary of these people who they may see as “preying hawks”. The lack of systematic and generally acceptable campaign fails to sensitize and inform people about concepts of “transplantation” and “brain death” The policy fails to give clear parameters in obtaining permission for post-mortem organ donation. Thus, reliance on a system like “presumed consent” or “mandated choice” on the matter becomes a weak stand. As a result, the decision for cadaveric organ donation ultimately falls on the next of kin of the deceased. Lack of training for hospital personnel to be effective in facilitating cadaveric donation. This lack of effective and specialized staff in many instances led to miscommunication with potential donors’ families which in turn resulted to unnecessary conflicts and finally the loss of potential donations. It is easy to see how all of the above prevents patients in need of transplantation from receiving what they need. These are the major reasons why the cadaveric donation rate has remained very low at 5.7 per million of the population (PMP) by the end of 2006 (Europa Public Health, 2007). On the other hand in the case of organ donation from living persons the CNTPP has been more successful. This is mainly because Cypriot families are very close-knit and caring. Thus, they are very willing to help out especially when a member of the family is diagnosed with end stage renal failure. These attitudes explain why Cyprus has pre-eminently remained among the EU states with high living donor transplantation rate 54.3 PMP (Europa Public Health, 2007). However, since those patients are in our care, we likewise feel the burden. The increase in the waiting lists means that the patients can expect prolonged suffering, declining health and rising death rates as long as the organ shortage persists. These major consequences can be summed up as the following: firstly, the suffering and expenses to sustain living of the patients become prolonged. Secondly, their health deteriorates meaning they may not be able to withstand the stress of the transplantation when it finally comes, thus reducing its success rate. Finally, deaths are inevitable as a direct consequence of the inability to obtain the needed organ for transplantation within the time frame prescribed. My position as a transplant procurement coordinator becomes a strong link between possible organ donors and organ recipients. However, much pressure has been put on my shoulders as I try to persuade unaware families to give their consent to harvest organs from their deceased loved ones which in almost all cases, consent from the deceased is unavailable. Impact of Practice on Policy Focusing on the horizontal dimension of policy this time, the altruistic organ donations that have been relied on for years by medical practitioners are now being questioned along with the procurement policy. To augment the shortage of organs donated for transplantation, there has been a series of largely ineffective policy responses that ranges from increased educational spending to donor cards to the latest strategy that involves diffusion of “best practice” procurement techniques (Beard, Jackson & Kaserma, 2008). With live organ donors, there is less pressure in procurement since altruistic motivations still remain strong because donors are mostly family members of the organ recipients. In Cyprus, practitioners along with patient’s organisations and the Ministry of Health raised discussions regarding the CNTPP insufficiencies and how these can be improved. Finally, the authorities decided to reconsider the act for “Abstraction and transplantation of biological human substances of 1987” which is now under revision, in an effort to enhance cadaveric donation. It is anticipated that the final act will have direct impact on CNTPP. Through the several discussions that have been established and concluded, the key issues to be included in the new act include: 1. The establishment of the National Transplantation Council which will: a) Supervise the allocation, safety, quality, traceability, equity and access of needed organs for transplantation according to the European Union directives. b) Contribute to the organ procurement efforts by promoting and sponsoring campaigns through the media, organising educational programs in high schools and general in the community and finally to co-operate with political and religious authorities so that to promote the idea of donor’s card. c) Collaborate with foreign councils for organ exchange. 2. A clear and legitimate system in which all the citizens may express their will for opt-in or opt-out in organ donation. Such a system will liberate practitioners up to a point when conferring with families as they will have in hand the deceased’s wish. 3. The establishment of the post of in-hospital “transplant coordinator” following the Spanish model by which Spain managed to pre-eminent among the European countries in cadaveric donation with a rate 33.8 PMP. According to this model specially trained practitioners either nurses or doctors have been allocated in each hospital as transplant coordinators. This post will be of great importance since this role is multidimensional. This person will deal with the location of potential donors mainly from Intensive Care Units, conferring and providing thorough information to donor’s family and reassuring signed consent. Eventually, He/she will also oversee the coordination of the transportation and allocation of the organs, supporting the deceased’s family, as well as caring for the deceased during pre and post organ removal.  In 2007 the Ministry of Health decided to try posting transplant coordinators in one hospital and the results were remarkable. By the end of the year the cadaveric donations from 5.7 PMP at 2006 rose to 12.86 PMP and the next year, to 18.57 PMP. Such alterations spun from practice will render the policy more credible and acceptable to more people. Implications for the Future Clearly, organ procurement policies including the CNTTP have been thoroughly studied by practitioners since its inception. Much feedback and attempts at improvement of the policies have been learned from practice. Literature has provided a variety of solutions to bridge the deficiencies of the policies and the following are proposed for future practice: Improved efficiency of the organ procurement process where potential donors actually become donors. Efficiency may be increased by 80 percent by increasing awareness of the donation process and forging strong state legislation to increase the knowledge of the donation process with strong emphasis on family consent to donation (Altshuler and Evanisko,1992 in Dewar, 1998). The dissemination of information must come across as for the public good and not as a marketing tool for particular providers of such service. This means that information is provided to improve the efficiency of the organ market and not limited to manipulating patient preferences for particular providers. (Dewar, 1998). This noble intention would result in a larger number of organs procured for more potential recipients, hence shortening the organ demand list. Donor empowerment through knowledge of the organ donor system will create a more efficient organ registry system. This registry will be comprised of organ donors with more informed decisions. Equitably, demanders of organs would also be requested to donate some of their useful organs themselves in the case when they are needed. To accommodate the increasing number of potential organ recipients, the organ donor pool may be extended to include marginal donors such as older or obese donors, as it has been shown to achieve similar patient survival rates as long as there are no concurrent risk factors involved. Dewar (1998) explains that increasing the donor pool in this manner will utilize less health care system resources in the organ search and allocation process, thereby lessening the costs of the transplantation process and increasing the efficiency of procurement. The future looks bright for CNTPP since more concrete evidences to support proposed revisions to the policy have been garnered from practice. Conclusion As a breakthrough in medical science, organ transplantation is a welcome intervention for patients suffering from lingering diseases. The prospect of lengthening lives with a better functioning organ gives much hope for recovery and most likely, resuming a normal, healthy life from thereon. Policies on organ procurement and transplantation, specifically the Cyprus National Transplant Procurement Policy (CNTPP) for the people in Cyprus have been created to ensure the safety and health of all concerned. However, like most policies, it has raised issues and concerns and even moral dilemmas regarding organ procurement. My practice as a haemodialysis nurse and transplant procurement coordinator has been directly affected by the CNTTP. Tasked to source prospective organ donors and facilitate the procurement of necessary organs, I have been in a challenging position to relay important information to the families of prospective donors as well as assuage the anxieties of the patients in dire need of organ transplantation. I am aware of the fact that their list is growing as time passes due to the shortage of organ donors. Getting to the root causes of such shortage has revealed to me a number of conflicts that need to be resolved if the CNTTP is to be effective. The two sources of organ donation are live human donors, mostly close family relatives of the patient in need of the organ, and cadaveric donors. Live donors usually do it for altruistic reasons in the hope of saving the life of a loved one. On the other hand, in the case of cadaveric donation the issue of consent of the deceased donor comes into question. Usually, such consent is manifested by a signed organ donor card that the deceased has in his/her possession, or else, he/she has, when alive, explicitly expressed willingness to donate his/her organs upon his/her death. The unavailability of such presumed consent turn the responsibility of providing consent to the next of kin. This is where most of the problems with organ procurement rest, as most family members may be reluctant in disturbing the peace of dead and may hold various views in organ harvest. One solution that has been proven effective, as exhibited by the Spanish model is the employment and thorough training of transplantation coordinators whose sole duty is to effectively provide information and sympathetic communication with the family members. These coordinators are credible enough to know about the transplantation process as they are doctors and nurses; however, they maintain their objectivity as they are independent of the transplantation team. Family members usually need reassurance that giving their consent is the right thing to do, and is aligned with the wishes of the dearly departed organ donor. This paper has discussed the impacts of policy on practice and vice versa, and in the process, I learned of possible ways to augment the shortage of organs needed. Dewar (1998) explains that all the methods proposed to increase the supply of organs have great potential to also increase the efficiency of the procurement process and cost-effectiveness of the transplantation services. This is possible with the reduced cost of organ acquisition with the consent of the donors’ families as well as the improvement of equity in the organ allocation process. This way, a greater number of potential recipients will have access to the organs they truly need to survive. With this in place, I am assured that my practice as transplant procurement coordinator becomes more fulfilling as the new revised policy will work to the advantage of my practice and I am in a better position to help more people in need. Read More